Physician behaviors need to be managed starting in their training programs. In medical school there needs to be a didactic component that instructs around the the ‘managerial” and “teaming” components of medicine. During residency key portions should include the same training and instruction that new managers receive around leading, coaching and accountability. Until that occurs we will continue to have physicians employed and voluntary on our medical staffs. At this point a formalized program to have physician to physician conversations around these issues is necessary. This will allow for the “education” to occur help shift the behaviors. Egregious behavior needs to be dealt with quickly by the medical staff leadership which will start setting the tone and pathway forward. Taking advantage of cultural issues, like the current #metoo movement creates a platform for educating physicians around their law and by extension their own behaviors.
As healthcare continues to merge and larger and larger organizations become the standard model this is a problem that will continue. Changing the nature of the overall structure of the organization will help “translate” services across silos. Often the dispirsment of “best practices” does not occur because the best practice requires additional inputs abover the current operating model and or the restructuring of work teams. Multiple structures can be employed to help address this issue. Having a central Project Mananagement Office that deploys project managers to assist end operating units would help translate established services through out the organization. If the end unit wants to impliment Telemedicine it would engage their region’s PMO coordinator who would help scope the project, determine deliverables and add consulting project manangement support and oversight. Part of the project would include the PMO asset surveying the organization for “existing or best practices” and then bring that information back to the requesting end entity. They would also bring back practice to the central PMO team. Additionally they would provide “expert” PMO support to end operating units.
Around communications a single EHR that all business units use with an alert system that automatically pulls up patient touches in the last 24 hours to alert the provider. Also designated “patient reps” that have the responsibility for serving as the patient’s navigator for the whole organization who – following scripts – to primary communication and health coaching with the patients could help mimimize the multiple communications and also help keep patients within the health system.
Traditionally co-management agreements often struggle after the first couple of years as the cost savings and revenue sharing opportunities decrease. However with the transformation of healthcare that is occurring today the opportunities to share in the upside of this transformation make this model once again viable. The largest challenge will be to define an arrangement that meets the regulatory safe harbors related to Stark and Anti-kickback laws. Employement often services as the easiest harbor but it certainly is not the only one. One opportunity I have used in the past was to create an “institute” or “center” in my Hospital that provided the physicians the opportunity to have a percentage of any upside contribution margin over budget placed into a “restricted” fund that could be used to purchase capital equipment, hire additional support staff, fund resident over the program’s “allocated cap slots” fund research project and the like. There was no income distributed back to the individual physicians but gave them more “ownership” and control over their program and how it is resourced. By the funding coming from performance over budget and a percentage of the overage there is little drag on the overall portfolio.
A couple of thoughts.
1) Is there the opportunity to move some of the elective cases to outpatient or extended recovery and having those go first each day. While this would require “recovery” space it would help decompress the inpatient side. With joint replacement now being reimburse as an outpatient by Medicare the traditional LOS for many elective cases should decrease. Concerns with patients having issues once home could be alienated with a “at home/post discharge” visiting nurse program or an option where patients send in key vitals to the EHR for servalance. For high volume cases having a pre-surgical “boot camp” setting this expectation with patients and making sure they know how to set themselves up for success before they have surgery to make the discharge to home easier.
2) Increasing bed compliment – expensive but always and option
3) Create a clinical decision unit / observation unit. If observation patients are mixed in with full admits they will be managed by the doctors and staff as if inpatient increasing the length of stay. Even shaving .25 off the LOS of obs patients can increase throughput.
4) Also have a goal for all discharges to be determined by 9 am so patients leave by 11 am. Establish a discharge lounge for patients who can’t leave at 11 due to social issues. Again creating more capacity.
At the leadership level the technical expertise becomes secondary to the behavioral and leadership skill set. Determining if the individual’s job is to preform the technical work (or quality assure the work) or lead a team and project is necessary. These often are two different skill sets. For this specific issue I would recommend, first developing a solution to complete the project on time if this person leaves and then work on coaching the behaviors or pairing with a leader who can manage the negative behaviors and serve as a buffer. With a highly matrixed work environment it can be difficult for individual leaders to flex enough to be successful.
Certainly a tall order!
The board will want to have a good understanding of the plan to achieve budgeted targets and the pathway to success. As a new CEO coming in there should have been an expectation from before starting that the first 100 days would be assessing the organization and performing a SWOT analysis of the overall company.
It is clear the biggest weakness and threat is the employee moral issue. Focus here will be paramount to any future success. Creating a non-negotiable culture around employee engagement is necessary. Leadership from the top down should focus on the key areas of staff engagement, connection to the purpose of the work, clear expectations of the job, the basic tools and equipment to do their job, recongnition for contributions to the team and an opportunity to provide input to changes within their areas. This is not an easy task and falls to the most junior leaders – direct supervisors. I would recommend implementing a structure around these areas immediately. The importance of this endeavor can not be under estimated and may require an outside resources. This would be an ask of the board for support of this direction and funding. Also creating a sub-committee of the board to oversee the progress in this area could be helpful to show consistent improvement.
Communication to all levels of the staff and a “playbook” on how we will communicate, the words we will use and how we will refer to business entities will be important. And clearly identifing communication channels and expectations around engaging in those channels will be necessary as well.
Finally preparing a road map to walk the board through just how dire the situation is and then providing the plan with key deliverables and time frames will be important to develop a realistic and achievable budget and expectation for performance in the near (24 months) term.